Medication-Related Osteonecrosis of the Jaw with Spontaneous Hemimaxilla Exfoliation: Report of a Case in Metastatic Renal Cancer Patient under Multidrug Therapy

Abstract

Medication-related osteonecrosis of the jaw (MRONJ) is a well-recognized complication of drug therapies for bone metabolic disorders or cancer related to administration of antiresorptive (bisphosphonates and denosumab) and antiangiogenic drugs. This report describes an advanced and unusual case of stage III peri-implantitis-induced MRONJ involving the right upper jaw which was attempting to self-exfoliate. A 61-year-old male patient, rehabilitated with the placement of two implants when he was still healthy, was suffering from metastatic renal cancer previously treated with bevacizumab, interleukin-2, zoledronic acid, denosumab, cabozantinib and nivolumab. He had been under treatment of nonsurgical therapy over a year, based on antibiotic and antiseptic mouth rinse, without improvement of oral conditions. Surgical treatment consisted of massive sequestrectomy and complete surgical debridement of necrotic bone tissues. The specimen was sent for histopathologic analysis, which confirmed bone tissue necrosis with no evidence of metastatic disease. Two-month follow-up revealed a considerable life quality improvement. Although this complication is well known, the uniqueness of this case is given by its severity, related to the administration of multiple antiresorptive and antiangiogenic drugs, by the natural response of the oral cavity with the almost complete self-exfoliation of the massive necrotic zone. This case is emblematic in highlighting the controversies in the management of MRONJ, which certainly require effective collaboration of the multidisciplinary health care team that could improve patient safety and reduce the risk of developing MRONJ.

Medication-related osteonecrosis of the upper jaw involving the zygomatic bone: A case report

“…Long-term antibiotic administration may promote the development of resistant strains. Case have also been reported in which MRONJ progressed after prolonged conservative treatment and required extended resection [8] . A position paper of the American Association of Oral and Maxillofacial Surgeons (AAOMS) reported in 2022 also included surgery as an option for MRONJ treatment [9] .…”

Efficacy of fibrin-rich platelets and leukocytes (L-PRF) in tissue repair in surgical oral procedures in patients using zoledronic acid—case–control study

“…MRONJ is a well-recognized complication of drug therapies for bone metabolic disease or cancer. Antiresorptive drugs, such as bisphosphonates and denosumab, are been used in low and high doses, and a recent literature review identified a range of other medications classified as tyrosine kinase inhibitors, monoclonal antibodies, mammalian target of rapamycin inhibitors, radiopharmaceuticals, selective estrogen receptor modulators, and immunosuppressants that have been implicated in MRONJ in addition to the drugs already mentioned [22]. Many studies have investigated the mechanism of MRONJ development and various therapeutic methods have been proposed but still poorly understood [23,24].…”

Osteonecrosis of the jaw: a rare but possible side effect in thyroid cancer patients treated with tyrosine-kinase inhibitors and bisphosphonates

“…Very recently, another case of a 61-years old male patient who developed an advanced and unusual case of stage 3 peri-implantitis-induced MRONJ involving the right upper jaw was described by Bennardo et al [ 47 ]. For a metastatic RCC, starting from May 2017, the patient received interleukin-2 subcutaneously 3 weeks a month, twice a day for 5 days a week, and then, from June 2017, bevacizumab, every 2 weeks, for 6 months.…”